Did you take part in the WVVMA Student Contract Program at our partnering schools (MSU, Auburn, VMCVM)?*

Yes

No

May we share this information with your Alma Mater?

Yes

No

I would like to opt out of such circumstances where name and practice information may be released to business partners of the association.

Yes

How would you prefer to receive our quarterly Factline newsletter?*

Printed, by Mail

Digital, by E-mail

If printed, please indicate the preferred address to send the newsletter

Practice

Home

**New Members Only** Were you contacted or referred by a WVVMA officer, member, or corporate sponsor? If so, please list who contacted you:

Area of Practice:

Companion/Small Animal

Food/Large Animal

Equine

Mixed

Exotic

Government

Faculty

Industrial

Other

If you selected "Other" above, please explain:

Please check below all of the information that you are comfortable with the WVVMA publishing within our 2017 directory. This will be available only to fellow members of the WVVMA.*

Practice Name

Practice Address

Practice Phone Number

Email Address

Home Address

Home Number

Membership Type:*

Active Membership (In-State Veterinarian): $195.00

Associate Membership (Out-of-State Veterinarian): $70.00

Life Membership (for WVVMA Members of 40+ years and/or over 70 years old): Free

2016 New Graduate Membership: Free

Total

$0.00

Credit Card

American Express

Discover

MasterCard

Visa

Card NumberExpiration DateSecurity CodeCardholder Name

Billing Address*

Street AddressAddress Line 2CityZIP Code

Note (do not fill out):

Dues payment to WVVMA is not deductible as charitable contributions for federal income tax purposes. However, the portion of the dues not attributable to WVVMA legislative affairs may be tax deductible as ordinary and necessary business expenses. The WVVMA estimates that 11% of your 2016 dues are attributed to legislative affairs and are not tax deductible for federal income tax purposes. Retain this portion of your statement for your 2016 tax filing. Consult your tax advisor.